Fighting Cholera amid Haiti's Debris

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Less than a year after its massive earthquake, Haiti has been hit with an outbreak of cholera that threatens to spread to some 1,300 displaced-persons camps in Port au Prince. Cholera, transmitted through water contaminated with fecal material, is treatable with proper hydration and antibiotics, and preventable with clean water and good sanitation, says CFR's Laurie Garrett, but Haiti has long suffered from unsafe water and poor sanitation infrastructure. While Haiti reconstruction funding is slotted for that infrastructure, "most of Port-au-Prince is still debris," says Garrett, so "it's hard to build plumbing systems [and] water treatment systems." Garrett says the outbreak may have been started by Nepalese peacekeepers, raising the question of how to prevent this kind of disease transmission.

Can you give an overview of this cholera epidemic and what it means for Haiti?

Actually, it's a pandemic. This particular strain of cholera, known as the 01 strain, first emerged in the Bay of Bengal in 1992, causing devastating epidemics in India in '92, '93, and '94. It then went quiescent, and there was hope that perhaps it had simply run its course and would disappear. But by 2000 it had reemerged in the region and had completely replaced what's called "classic cholera," the sort of genetic subtype of cholera that had been in the world for thousands of years. It seems to be more virulent than classic cholera. It tends to have more drug-resistance capacity, though that is not a uniform finding.

But the really big story here is that it then broke out in Nepal, around 2003-04. It now appears, though we're awaiting more confirmation at the laboratory level, that this pandemic in Haiti started with Nepalese peacekeepers who were the carriers. We have similar outbreak-carrier situations now in several places in the world. In fact, the largest cholera outbreak at the moment is Nigeria, with far more cases than are being seen in Haiti.

This poses difficult questions related to peacekeeping operations and how we have humanitarian workers traveling all over the world going from one crisis situation to another. You want them to do so, but you can't test everybody for everything.

What would work in terms of dealing with aid workers preventively? The cholera vaccine?

It's not a terribly great vaccine. It doesn't give long-lasting protection. There are side-effects, and it's extremely expensive. Actually, if aid workers and peacekeepers were taught proper hygiene and provided with toilet paper and proper soap and so on, they would not be transmitters. The problem with cholera is that it really is a classic hygienic issue. The spread of cholera is about water, it's about dirty hands, touching water supplies and food supplies, and about the inability to limit what's going into the water because either there are improper sewage systems; or people are drinking from, washing in, and defecating in the same water supply.

It's inexcusable that we cannot control cholera today. We fully understand the disease. It is generally treatable with a combination of appropriate antibiotics. But most important is heavy-duty hydration with consistently safe water.

The other issue is part of the reason cholera is always a crisis in the Bay of Bengal region--because the microbes, especially this 01 form, can live inside of other microorganisms that float around in such things as red tides and algal blooms. Wherever you have very warm surface temperatures, relatively still waters, lots of sun, you're creating a kind of stew that's ideal for the growth of the microorganisms that the vibrio cholerae [the organism that causes cholera] can live inside of. You get this constant feedback-replenishment thing going on where problems on the land mainly associated with humans--waste and water runoff--feed into breeding colonies in the sea, and vice-versa. We had a classic outbreak of cholera that hit Latin America in the 1990s, and it turned out to have reached Latin America because of ships loading bilge in the Bay of Bengal, going across the world, and offloading the bilge water into coastal waters where they were absorbed into clams, shell fish, oysters, and so on. Then you had an epidemic that spread across Latin America. If you don't have very good public health tracking systems, general population hygiene, and water safe systems, it spreads extremely rapidly.

Infrastructure for water and sanitation in Haiti has long been notoriously poor.

Haiti has longstanding problems with water. The whole Caribbean does. Historically, some of the worst cholera epidemics were in fact in the Caribbean and in New York City, carried from Caribbean trade up the coastline on the Atlantic. Two hundred years ago, from around 1800-1812, New York City had cholera epidemics so devastating in the summer that as many of 5 percent of the children died. And they didn't have a germ theory of disease at that time, so there wasn't a clear understanding of why it was happening.

But it's inexcusable that we cannot control cholera today. We fully understand the disease. It is generally treatable with a combination of appropriate antibiotics. But most important is heavy-duty hydration with consistently safe water. The main thing with cholera is that you dehydrate. And death is associated with massive dehydration. If the water is the source of the cholera and you rehydrate with that water, you're simply redosing yourself with the microbe, and you subsequently die. If you have safe water, you can slow down the pace of dehydration. Then you can slam with the appropriate antibiotics.

The real issues are threefold. In Haiti--or in Nigeria, where the epidemic is far larger--you want to get in quickly with appropriate safe water supplies, soap, and hygienic training, and you want to set aside folks who have cholera in designated facilities. Hydrate them heavily and give them the appropriate antibiotic treatment. You should have a very high rate of recovery, and you should be able to bring things to a halt pretty quickly.

If cholera becomes endemic in Haiti, what does that mean in terms of Haiti's redevelopment efforts?

It puts a lot of urgency on getting the infrastructure developed much more rapidly than has been the case so far. In particular, separate sewage and drinking water systems. The nature of what needs to be done is not exotic and frankly not all that expensive. We know how to separate our pipe systems and how to do sewage treatment, and we know how to get vibrio cholerae and other dysentery-causing diseases out of the water supply. It's just been a slow pace in Haiti and one that is frustrating everybody.

Why? There's aid money flowing into Haiti, and people have known about the deplorable sanitation and water systems in Haiti for a long time.

Actually, money isn't flowing in. Congress approved more than $1 billion for Haitian relief, but only small increments of those funds have made it out of federal coffers, both for reasons at State and on Capital Hill.* So while dollars have been committed, they've not flowed at a rate that would allow us to feel comfortable that there is sufficient funding. Bulldozers and heavy lifting equipment to deal with the debris and to destroy shattered buildings only started moving really in the last couple of weeks on a major scale.

It's shocking how far down the road we are without doing what you would do in any American city in a similar situation--mow down anything that would have been declared unsuitable for habitation and then start rebuilding. But most of Port-au-Prince is still debris, and it's hard to build plumbing systems, sewer systems, water treatment systems when the debris is sitting in the way. However, I have to say that it's my understanding that most of the water being distributed in the form of drinking water in Port-au-Prince is actually coming from specifically pumped water stations. That may actually protect Port-au-Prince from a serious outbreak.

Will the cholera outbreak affect the November 28 presidential and legislative elections?

I don't see any reason why this should affect the elections more than any five or six hundred other things going on in Haiti at the moment. Actually, the really scary thing is that we now have confirmation of deaths due to cholera, the same strain, in Pakistan in the flooded areas. It is probably the case that a widespread cholera epidemic in Pakistan would have more impact politically in that country than the fairly limited outbreak of cholera in Haiti at this time.

It's shocking how far down the road we are without doing what you would do in any American city in a similar situation--mow down anything that would have been declared unsuitable for habitation and then start rebuilding.

The long-awaited Quadrennial Diplomacy and Development Review (QDDR) is due soon. What do you want to see in there?

As far as we can tell, from the hints out of the State Department, most of the development community will be pretty happy with the QDDR. The global health community may have more quibbles. The Global Health Initiativeis finding resistance in the HIV/AIDS community. That community is not happy with most of the way that the initiative is structured, so you have some grumblings among the troops on the ground and the advocacy communities.

What are the issues?

From the point of view from the folks dealing with HIV/AIDS, there's really only one issue: "Give us more money and more independence to spend that money the way we want to." The Obama administration has really had to rein that in and say, "Look, there's got to be a structure, there's got to be accountability, there's got to be demonstrated outcomes." It's created quite a bit of tension between the HIV/AIDS community and the White House, to a degree that at the international AIDS meeting in Vienna [in July] there were posters stuck up all over the meeting by Americans that showed a split view of half of President Bush's face and half of President Obama's face smooshed together like a single face and it said underneath, "Which one was better for HIV/AIDS?" The answer was implicit that it was George Bush, mainly because of the scale of the dollars committed.

Are these complaints legitimate?

The scale of growth, the pace of growth, [and] the financing for HIV/AIDS has slowed. It is still growing, but at a much slower pace. If that's the primary metric by which you judge success or failure of U.S. foreign policy vis-à-vis AIDS, then yeah, you'd be grumbling. I don't think that's the appropriate metric.

The irony is that more people in Africa in particular, but developing countries generally, have been able to acquire HIV treatment thanks to PEPFAR [U.S. President's Emergency Plan for AIDS Relief] in the Obama years than PEPFAR in the Bush years. Programs are maturing, so during the Bush administration this was all brand new and people were trying to figure out what they were doing. Also, a big shift that the Obama administration executed was to get away from contracting out so much of HIV/AIDS efforts in developing countries. Now more of the burden of caring for people with HIV/AIDS, and of prevention programs, is being carried by the ministries of health and their own country programs. This is with the goal of eventually leaving these countries self-sufficient.

One of the big challenges is to look forward on this pandemic, out ten years, and try to imagine how we are going to deal with this if we don't have a vaccine. Nobody can figure out how this is a sustainable effort unless you can get the countries to embrace the majority of the burden themselves, absorb it into their national governments with assistance from the outside, bring down the prices of generic formulations of the key drugs--both first line and second line--and get serious prevention efforts going that bring down the burden of the numbers of newly infected that will require treatment down the road.

The Obama administration's global health initiative, in conjunction with changes going on in some of our partner donors is to begin to integrate things so there's a whole battery of front-line primary care that people get all from the same facility. It would include HIV workups, tuberculosis workups, education about malaria and bed-net distribution. To get back to Haiti, one of the hopes that has been voiced repeatedly by [former] president [Bill] Clinton, who's acting as our chief ambassador on this whole Haitian recovery, has been: We've got to take advantage of this moment to build those kinds of integrated approaches to bringing health into people's lives.

* Editor's Note: This response has been changed to remove a mistaken statement that Senator Tom Coburn had held up congressional funding for Haitian relief.

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